I felt this way before by under very different
circumstances, almost 10 years to the date. I am writing reflections about the events of the last few weeks,
culminating in a feeling of near despair. I've been there before, writing
thoughts as a therapy session, returning from Haiti one week after that
infamous earthquake (NYT). I never felt any
fear of heading to the stricken island. On returning, post-traumatic stress
quickly set in. But somehow, the same
feelings brought back its ugly head - this time, I have a sense of
anger.
I was driving home last Friday. As usual, XM radio was on CNN. The press conference with the chief
politician came on. Yes, the bickering
started. This time it was a fight
concerning how many respirators the federal government will send to New York.
Have mercy; I thought, patients would die without ventilators. All the bragging
and ignorant noise irritated my nerves. It takes careful staring into the
patient's cough to insert a breathing tube into the trachea withing a short 20
seconds. "Let them f--- try this without PPE (Personal Protective Equipment,"
I shouted in the car, slamming on the gas pedal. Where are the flipping PPEs? Doctors, nurses,
respiratory therapists, and other hospital workers lacking proper equipment,
not enough ventilators - is not supposed to be happening here. We are in the
USA. Now, I know why I feel sad and irritated.
In preparation for a coming wave of sick people stricken by
the coronavirus, allow me to share my reflections of last week. More anomalies were comparing a tragedy in
the US with that of the poorest country in the hemisphere, Haiti felt like
deja-vu.
Thank God, this viral syndrome does not affect children as
much as adults. So, we had weeks to
prepare our pediatric area, train our teams, and gather our materials at my
hospital (TBHC).
I imagine an earthquake with early warning signs. These were not aftershocks before a second
big one, but now it's three months since the outbreak in Wuhan. What shook me up is the fact that China rushed
to build two hospitals in only two weeks at the same time declared a draconian
quarantine protocol. The Chinese
certainly sounded the alarm, a warning that the world did not heed.
The surge plan for the pediatric area will be near
completion by next week. The New York mandate came out, Gov. Andrew Cuomo Orders Hospitals to Increase Capacity by 50%. We quickly planned to double our
private rooms, fit them with double-wall oxygen supply. At the same time, pediatric patients with
mild illnesses will stay home or discharged and managed over the phone. As the crisis mounted, the pediatric floor
remained quasi empty. We quickly
realized that we would have to increase our age range from 21 to 25 years of
age and higher because of the swell of adult patients crowding the emergency room. The daily change in conditions urged us to
come out of our comfort zone and begin caring for young adults in a way to
decongest the adult floors.
One lesson learned after the Haiti earthquake was a gross
lack of training for necessary resuscitation procedures. A grave shortage of human resources was also
evident. As we surged our space
capacity, an apparent shortage of nursing staff came in view. Before the
weekend, pediatric residents shifted from their regular duties, and seven
received basic training in nursing ICU duties. The goal was to pair them with a
skeleton staff of nurses to augment the staff capacity because several of them
had fallen sick to the disease.
During the same week, news broke from Italy. Doctors were no
longer placing patients older than 60 years on life-sustaining equipment. In
essence, they first considered younger patients with a higher chance of
survival. Déjà vu. My earthquake experience in Haiti taught me
well. I chose to give the last shot of ceftriaxone [an antibiotic] left to a
patient who underwent a successful amputation for a gangrenous leg over a
gasping pediatric patient in severe sepsis.
This scenario is not novel, frequently simulated in NY state with
drafted guidelines to ration scarce resources.
We have watched documentaries about pandemics and attended disaster
courses, informed about stockpiled ventilators for something just like this.
Well, here we are, actually writing a policy allocating scarce resources in a
time of crisis. As I read through the draft document for my hospital, there was
little relating to children. I began
thinking; we now have two very sick children both on respirators. Could we ever consider withdrawing one or two
of these challenged patients for the benefit of another with greater longevity? What if a premature infant birthed at a time
to compete with a healthy 21-year-old with COVID-19 infection in respiratory
failure? Would this policy call for
someone to be "King Solomon"?
That same night as we nearly converted our pediatric floor
to accommodate adults, a seven-day old presented with severe jaundice. His pediatrician frantically called-in for a
bed. She insisted on having him stay
close to the community as other large hospitals were diverting all pediatric
patients far away from home. We had to
make space. How could we manage such a
massive influx of sick patients with coronavirus infection and ignore our
community of patients with sickle cell disease? This other patient also
required special attention.
President, PULSE https://www.facebook.com/PULSENOW/
Chief, Pediatric Critical Care
Director, Pediatric Inpatient Service, TBHC
Assistant Professor of Clinical Pediatrics
Icahn School of Medicine at Mount Sinai
